APPLICATION FORM FOR INTERNATIONAL RELATIONS CONFERENCE 2011
Application deadline: 13 May 2011 Please read the accompanying letter for the regulations. Completed forms should be returned to: Annette JE Fisher English-Speaking Union, Dartmouth House 37 Charles Street, London W1J 5ED annette_fisher@esu.org by 13 May 2011 by email, fax or post Details of application Country applying from: Personal Details Please attach a passport sized portrait photograph of yourself to the front sheet Title: First Name:
Family Name:
Other names: Please indicate by which name you prefer to be known, by circling it Date of birth:
Gender:
Nationality: Emergency contact details Name: Relationship to you: Phone number including international dialling code: Passport and Visa Information The information requested below is required when processing your visa and will not be used for any other purpose Do you require a visa to enter the UK? YES
NO
Do you require a formal letter of invitation from the ESU in order to acquire a visa?
YES
NO
Please give your name as it appears on your passport:
Contact details Name: Address to which all correspondence should be sent: _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Home/Mobile phone: _______________________ Work phone: ______________________ Email: All correspondence regarding the programme will be through email, please provide us with an email address which you check regularly. Dietary requirements Please let us know if you are vegetarian or have other medical/ethical dietary requirements. Though we will endeavour to insure that all dietary requirements will be catered for, it cannot be guaranteed at all meal times. Please tick
I am vegetarian
I have other dietary requirements
[Please give details below] _________________________________________________________________________ _________________________________________________________________________ Health Please include details below of any medical conditions you may have or medication you are taking and of which we should be made aware. [These details will remain confidential] _________________________________________________________________________ _________________________________________________________________________ Academic/Employment details Please fill out the relevant sections – see notes for details Current Occupation: Current place of employment/study: Please list all institutions of education attended from the age of 16 and qualifications obtained.
Name of Institution
Dates From
Qualifications obtained, year and grade To
Specific experience relevant to application
How did you hear about the International Relations Conference?
Personal statement All applicants must complete this section of the form Please explain, in no more than 400 words, how you think you would benefit from a scholarship to the ESU International Relations Conference and how the experience would help you in your current work and future ambitions. Please write and attach on a separate sheet. I have read and understood the notes and conditions for applying for a scholarship to the ESU. Sponsorship I will be applying for a scholarship from the ESU I am funding the place myself
The organisation I work for is funding my place
Declaration I declare that the information given above is correct:
Signature
Date: